Provider Demographics
NPI:1558916551
Name:MONTGOMERY, CORINA MICHELLE
Entity Type:Individual
Prefix:
First Name:CORINA
Middle Name:MICHELLE
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4408 HAMMOCKS DR APT 208
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-7427
Mailing Address - Country:US
Mailing Address - Phone:832-372-5336
Mailing Address - Fax:
Practice Address - Street 1:135 E 38TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16504-1559
Practice Address - Country:US
Practice Address - Phone:814-860-2197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-06
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX65028183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist